ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. A goal for a client with impaired mobility is to prevent skin breakdown. What nursing intervention would best help the client meet this goal?
- A. Assist the client to orthopneic position
- B. Offer the client a bedpan for toileting
- C. Offer a protein-rich diet
- D. Turn the client every 2 hours
Correct answer: D
Rationale:
2. Which of the following clients are at an increased risk for deep vein thrombosis following a reduction and internal fixation of the hip? (Select all that apply)
- A. A client on birth control pills
- B. A client who is immobile
- C. A client on an anticoagulant
- D. A client with dementia who has been wandering
Correct answer: a
Rationale: Clients on birth control pills, immobile, and smokers are at increased risk of DVT after hip surgery.
3. What may be a cause of conductive hearing loss?
- A. Prolonged exposure to loud noises
- B. Medications
- C. Presbycusis
- D. Otitis media
Correct answer: D
Rationale: Otitis media can cause conductive hearing loss by affecting the middle ear.
4. A nurse is providing oral hygiene for an unconscious client. What is the priority nursing intervention?
- A. Position the client on one side with the head turned towards you
- B. Handle dentures with care
- C. Use gentle brushing and flossing techniques for clients with fragile mucosa
- D. Have a suction apparatus ready at the bedside
Correct answer: A
Rationale:
5. A nurse is caring for an immobile client. What is the priority assessment of this client?
- A. Palpate for edema
- B. Auscultate for bowel sounds
- C. Inspect the skin for injury
- D. Auscultation of lung sounds
Correct answer: C
Rationale: Inspecting the skin for injury is crucial to prevent pressure ulcers and other complications in immobile clients.
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